This past week, Global News’ investigative team published an explosive investigation detailing how some pharmacists are making big bucks by scamming the Ontario Drug Benefit Program out of millions of dollars.

The ODB pays for medications for Ontario’s most vulnerable: children, the elderly and those on social assistance. When a qualified patient fills a prescription, they either don’t pay anything or pay a few dollars, and ODB covers the rest.

The program costs the province more than $5.4 billion a year.

Pharmacists bill the province every two weeks for medication dispensed to ODB patients and are paid shortly afterwards.

Dishonest pharmacists over-bill by tacking extra drugs that they never dispensed onto these bills so that they are reimbursed for more drugs than they have sold. Untold millions earmarked for the sick and needy end up in their pockets.

Former Order of Canada recipient Dr. Ranjit Kumar Chandra — who fleeced OHIP for $2 million — has lost his licence to practise in Ontario.

“Dr. Chandra concocted and applied a devious scheme to cheat the Ontario public, at a time when health care funds are stretched,” a College of Physicians and Surgeons of Ontario discipline hearing ruling stated.

“In the circumstances of this case, revocation is the only outcome — there is simply no room in the medical profession for such reprehensible conduct,” stated the decision.

“Dr. Chandra’s conduct directly impacted the public purse and a fine is required for general deterrence,” stated the decision, which also fined him $35,000 — the maximum available — and ordered him to pay the college costs of $16,500.

“When a physician such as Dr. Chandra abuses his power by defrauding the public health care system, he has breached the trust of his patients, his professional colleagues and society at large,” the decision states.

The ruling found Chandra recruited approximately 300 people to his scheme and more than $2 million in OHIP fees were paid to him over a four-year period while he performed little to no medical services.

He billed OHIP almost $200,000 for services while he was in Europe, the Middle East or India, the decision stated.

Ontario’s Ministry of Health is doing little to crack down on doctors who improperly bill OHIP, according to information obtained by CBC/Radio-Canada.

A freedom of information request shows the province has recovered only $1.1 million in illegitimate billings over the past two years, while the auditor general pointed in her 2016 report to some $6 million in fees improperly paid to doctors.

“This is a complete waste of taxpayers’ money, taxpayers’ money that was supposed to go to health,” said NDP health critic France Gélinas in an interview with CBC News.

“It is incomprehensible that when the government sees those kinds of mistakes, that they don’t recoup the money,” Gélinas said.

This suggests little has changed since 2016, when Auditor General Bonnie Lysyk criticized the health ministry for inadequately investigating fraudulent billing and for failing to follow up on physicians with a record of charging inappropriate fees to OHIP.

“The ministry lacks effective enforcement mechanisms to recover inappropriate payments from physicians,” Lysyk wrote in her 2016 report. “Unless a physician agrees to repay amounts voluntarily, it is very difficult to recover inappropriate payments.”

Part 10. Taxpayers Are Fed Up – And Want Something Done!

We conducted a survey recently to find out just how strongly Canadians feel about the matter of healthcare fraud, and some of the responses might just surprise you. Or not.

90% of those surveyed think that healthcare fraud is a serious concern and needs to be addressed, that fraud of tax money is not a victimless crime.

And they’re right. Losing billions of dollars each year to healthcare fraud is no light matter particularly when, as the Globe and Mail reported in January of this year, “provincial ER waiting times set a record of longest in history” and “even Ottawa’s Children’s Hospital of Eastern Ontario recently warned families about waiting times to treat children in the emergency department”. The article goes on to say that “fully half of our hospitals were operating at or above 100 percent capacity”. Think of how much this dilemma would be eased for us if we were to clamp down on the theft of our healthcare dollars.

73% feel that law enforcement agencies should be responsible for handling cases of suspected healthcare fraud; only 8% would trust this to the Colleges.

And why would anyone think the Colleges are willing to or even capable of appropriately responding to practitioner fraud? The provincial Colleges of Physicians and Surgeons seem dedicated to protecting doctors, not the public. In May of this year, the Toronto Star identified 159 disciplined doctors who held licenses to practice in both Canada and the US and found that fully 90% of these doctors’ public profiles did not report sanctions taken against them for offenses including incompetence, improper prescribing, sexual misconduct and fraud. Furthermore, unlike the U.S., there is no Canadian national database from which you can access licensing and disciplinary action taken on doctors. While the public push for greater transparency of College disciplinary actions has effected some minor reforms in some provinces, some of the provincial colleges remain ultra-secretive about their doings.

An overwhelming 99% think that a doctor or other health practitioner convicted of fraud should go to jail like any other criminal, have their license suspended or revoked, be required to make full restitution, or some combination of the foregoing. Less than one percent thought that just giving back the money and carrying on like nothing had happened is appropriate.

We think that jail time is entirely appropriate for doctors who have committed crimes. Why should they get a pass when others (those not holding medical licenses) have earned themselves prison time for fraud and thefts of lesser amounts?

On the subject of taxpayers funding doctors’ legal defenses, only 12% of survey respondents agree that we should pay their legal bills; 88% feel doctors should pay their own legal bills just like everyone else.

Taxpayers having to fund the protection of doctors accused of wrongdoing – whether medical, civil, or criminal – is outrageous. What other group expects the public to pay their legal bills? Let’s take the hundreds of millions of dollars that we pay to the Canadian Medical Protective Association and put it into hospital facilities instead. And let the doctors buy their own insurance and pay their own legal fees.

When asked about federal involvement in combatting healthcare fraud, the average rating was 7/10 in importance.

One survey respondent sums up the issue nicely:

Healthcare is a Provincial issue. However, justice and criminal code matters are Federal, thus the Federal Government MUST take part.

Also, I do not believe that anything other than the criminal justice system is adequate as professional associations and administrative systems create a two-tier justice system where professionals and ‘white collar’ criminals are treated differently. This allows professionals to operate under a different set of standards and, in my opinion, truly does bring the administration of justice into disrepute.

Finally, as I have actually, personally, investigated instances of institutional health care fraud, as a taxpayer I am disgusted that widespread fraud goes unpunished – even as an administrative or professional association punishment – and simply results in policy changes.

Fact: If Unchecked, Fraud Will Collapse The Country’s Vaunted Healthcare System In Just A Few Years

Part 1. Canada’s Health System Is Out Of Control

The Canadian Institute for Health Information (CIHI) reports Canada’s health care industry takes in an estimated $242 billion annually or just over $6,600 for every man, woman and child.

Canada’s healthcare spend is roughly the size of Finland’s entire economy, per the World Bank. It is more massive than the economies of Portugal, Greece, and New Zealand, and it dwarfs the gross domestic product of 146 additional countries.

But since most people can’t really get a grasp on what one billion is, let alone hundreds of billions, let’s put it this way:

Canada’s healthcare spend is a staggering $27.6 million per hour or $460,426 every minute of every day – 24/7, around the clock.

It is more money than any other area of the economy and dominates the country’s budgets every year.

It is getting worse

The cost is growing exponentially. The 2017 estimated cost is up from 2016 by almost $200 per person. In the year 2000, Canada’s health care spend was roughly half of what it presently is, so it has more than doubled in record time — it is, in fact, a 142 per cent increase over the course of 18 short years.

The most significant percentage cost growth has been for drugs which now account for 16.4% of the healthcare spend. That’s $39.7 billion (with a “b”), or $1,086 per person. This represents a 4.2% cost increase, double Canada’s annual inflation rate for 2017.

How much is stolen

How much of this cost is due to needless or even fraudulently prescribing or dispensing? A lot, according to Karen Voin of the Canadian Life and Health Insurance Association. She estimates that between 2 and 10 percent of healthcare dollars are lost to fraud.

So, let’s take the average of 6%. That means that we are losing $2.4 billion (again, with a “b”) every year to – and let’s call it what it is – the criminal element.

In Ontario alone, it works out to $118 million lost each year. And what does the Ontario Ministry of Health and Long-Term Care do about it? Almost nothing, sad to say. The Ministry recovers only a small portion of it. Bonnie Lysyk, the Auditor General, puts the number at a measly $5 million, or about 4.2% of what was stolen from us.

Your government doesn’t care

And even when the Province can be bothered to put on a show of looking for fraud, they don’t tell the police! The Auditor General’s office revealed that for the years 2013-14 and 2014-15, the Ministry reported zero (0) suspected fraud cases to the OPP. In 2015-16, the Ministry reported two cases.

We don’t just mean little or no suspected prescription drug related fraud cases were reported by the Ministry – we mean that little or no suspected healthcare fraud of any description was reported.

In August 2016, the Ontario Provincial Police (OPP) Anti-Rackets Health Fraud Investigation Unit had to take matters in their own hands and approach the Ministry to ask why they weren’t sending any files for investigation. (Perhaps the OPP should be investigating the Ministry.)

These are significant facts

And the most astounding fact of all is that no one is minding the shop. Not one health minister. Not one premier. And certainly not the Prime Minister of Canada.

Don’t believe us? Just call Canada’s Minister of Health’s office at 613-957-0200 and ask. You will be astounded. There is not a single agency that even cares what happens with the $662 million they give the provinces every single day!

Could this unconscionable negligence be the reason that Canada’s healthcare fraud is out of control? Because it is. In fact, it is so out of control it is threatening to bankrupt the country.

Part 2. Fraud Costs Canadian Taxpayers $14.5 Billion Annually

In his book “License To Steal: How Fraud bleeds America’s Health Care System”, Malcolm K. Sparrow, a professor with the Kennedy School of Government at Harvard University says:

“Health care fraud remains uncontrolled, and mostly invisible. For Americans, this problem represents one of the most massive and persistent fiscal control failures in their history.

“Many who work the system, or feed off it, like it so.

“For those who profit from it, health care fraud is not seen as a problem, but as an enormously lucrative enterprise, worth defending vigorously.”

In the U.S. numerous sources agree that fraud is at least 10% of all health expenditures, and the U.S. is a country that aggressively pursues health criminals to protect taxpayers – we don’t.

That is not to say that healthcare fraud is not an issue in the U.S. The U.S. National Healthcare Anti-Fraud Association estimates the loss to be in the order of $80 billion each year. That is a significant amount of money, but it is interesting to note that the U.S. population is almost nine-fold of Canada’s population but their loss to fraud is decidedly not nine times as high as ours. In Canada the per capita loss from fraud is about 60% higher than that in the U.S based on the U.S. estimates of 10% loss while we conservative Canadians put the average figure at 6%.

How America does it

At least a part of the reason for this discrepancy is that U.S. healthcare insurers, legislators and enforcement agencies take active steps to detect fraud. And the U.S. does not just pay lip service to the issue of healthcare fraud. When they find it, they go after it with a vengeance, and the perpetrators are very likely to find themselves behind bars!

Just last year, the U.S. Attorney General Jeff Sessions announced that “federal prosecutors have charged more than 400 people in taking part in medical fraud and opioid scam that totaled $1.3 billion in fraudulent billing”. The 412 people facing criminal charges include doctors, nurses, and pharmacists who, as the Attorney General so correctly noted “have chosen to violate their oaths and put greed ahead of their patients”.

In May of this year, a New Orleans physician who had scammed Medicare to the tune of $810,556 was sentenced to prison time followed by a term of home confinement AND had to pay back the $810,556 he’d stolen.

A New Jersey psychiatrist was convicted of fraudulently signing treatment plans with the intention of misleading Medicaid inspectors. She’s presently contemplating the prospect of five years in prison and a $250,000 fine at her sentencing to be conducted in August of this year.

This is just a small sampling of the vigorous pursuit and prosecution of healthcare fraudsters in the U.S.

Our inactivity

Do the Canadian governments exercise that same diligence in protecting the taxpayers? Emphatically, no, assertions to the contrary from the various Ministries of Health notwithstanding.

In Canada public healthcare money is issued on demand and without oversight. And it is this lackadaisical incompetence that has made the Canadian governments’ “efforts” at healthcare fraud control a laughingstock as reflected in Texas attorney James Moriarty’s comment that “OHIP doesn’t have sense to pour piss out of a boot”.

The Canadian Life and Health Insurance Association reported that “All Canadians pay for healthcare fraud. In North America alone, it is estimated that 2 to 10 per cent of all healthcare dollars are lost to fraud [an average of 6 per cent].”

That’s $14.5 billion every 12 months, $39 million a day or $1.6 million per hour. Every hour, around the clock.

And do the federal and provincial governments care? Not on your nelly. They don’t even keep track of the fraud that they do, by some miracle, manage to uncover. An article in a January 2013 issue of CMAJ (Canadian Medical Association Journal) reveals that there could be “Upwards of $20 billion per year being funneled inappropriately into someone’s pockets. But a precise breakdown of how much of that is respectively attributable to physicians, or to other health professionals, pharmacies or patients is entirely unknown, as there is no standardized reporting of cases of fraud in Canada or sharing of information between jurisdictions.”

So, what is the government’s documented focus with respect to safeguarding healthcare dollars?

Part 3. Canada Has No Interest In Fraud, Only In Spending

In the article “What you need to know about the Canada Health Transfer” of December 2016 the Globe and Mail reported “The Canada Health Transfer is the money the federal government sends to the provinces and territories to help pay for health care, which is a provincial responsibility. Ottawa can use the CHT to enforce the Canada Health Act, although, in practice, it rarely does.

The transfer can be clawed back if a province fails to uphold any of the act’s five principles:

universality,

comprehensiveness,

portability,

accessibility and

public administration.

So not only is protecting taxpayers from fraud clearly not one of these five principles, there is no law enforcement unit anywhere in the federal government that exists to deal with it. Therefore, it is clear that the feds’ health budget is practically free money.

Prime Minister Trudeau’s “health mandate” nowhere even remotely addresses the issue and the Royal Canadian Mounted Police, which is a federal agency that acts as provincial police for numerous provinces, has no health fraud mandate. Take Saskatchewan as an example, where doctors can use any of 3500 different billings codes and which “to some extent uses the honour system,” to quote a June 2017 article by CBC News.

The case of Ontario

The Ontario Ministry of Health and Long-Term Care claims in their website to be “committed to detecting abuse and misuse of the Ontario health care system”. And who, according to them, is committing the health care fraud? Persons who:

knowingly use a health card that is not theirs

receive OHIP services who are aware that as a non-resident of Ontario they are not eligible

knowingly gives false information to the ministry to become or continue to be an insured person when they are aware that they are not eligible.

The Ministry claims that they investigate “each and every allegation it receives regarding potential health insurance fraud”. Who do they think they’re kidding? Do they really think that tracking down someone from out of province who is using their cousin Fred’s OHIP card is going to put any kind of dent in the enormous health care fraud bill that taxpayers bear? The ministry makes NO mention of investigating fraud perpetrated by practitioners. There isn’t even a hint of it.

Hindering law enforcement

Ontario, unlike many of the other provinces, at least has established a police unit charged with the detection, investigation and pursuit of health care fraud. The Anti-Rackets Branch of the OPP (Ontario Provincial Police) has a Health Fraud Investigation Unit, comprised of 19 officers. But as noted in part 2 of our series, the Ministry has been very lax in forwarding suspected fraud cases to the OPP’s Health Fraud Investigation Unit.

In fact, after waiting in vain for years for the Ministry to send them some cases to investigate, this police unit had to contact the Ministry and ask that they send some. And what did the Ministry send them? The Unit received 13 cases, eight of which were considered as being too old to investigate. The Ministry stepped up their game in 2016-2017, reporting six cases of possible billing fraud to the OPP, but did not follow up to see whether charges had been laid or the practitioner convicted. The police, who will vigorously investigate suspected fraud, are being sabotaged by the Ministry.

And even when the officers uncover medical fraud and charge the perpetrators, the sentences are often so light as to be meaningless.

And did you know that pharmacists and doctors convicted of OHIP fraud are very rarely stripped of their licenses to practice by the Colleges that supposedly regulate these professions? Furthermore, did you know that doctors charged by the police with committing fraud are defended in court by high-priced lawyers that you pay for? Don’t believe it?

Part 4. When Doctors Are Charged, You Pay Their Legal Bills!

When celebrities like OJ Simpson are accused of a crime they are responsible for paying their legal bills. When mobster Al Capone was arrested in 1931 he had to pay for his legal defense. So did Conrad Black. And Alan Eagleson. This is the case for everyone. Right?

Wrong. If you are a doctor in Canada you enjoy legal protection of the highest caliber, funded by the taxpayers!

In September 2015 the Toronto Star published a scathing indictment of a secretive and largely unknown organization, the Canadian Medical Protective Association (CMPA). Their article was entitled “Suing a doctor? Your tax dollars will be used against you: Canadian physicians are backed by $3.2-billion war chest indirectly funded in part with public money.”

“Following a medical procedure, you find yourself suffering from a serious, unexpected health issue you believe was caused by negligence. You decide to sue your doctor for pain, suffering, loss of income and the costs of care. Here’s what you may not know: you won’t just have to pay your own lawyer. Your tax dollars will finance top-flight lawyers to vigorously defend your doctor and challenge your claims.”

Yes, readers, that’s right. The CMPA is a publicly funded defense organization for doctors accused of wrongdoing. Doctors pay fees to the CMPA and then are reimbursed a hefty percentage from the public coffers, to the tune of hundreds of millions of dollars each and every year. CMPA financial statements show their membership revenue to be $566.2 million for 2016, and that expenditure has been steadily rising well ahead of the general rate of inflation. You paid most of that.

And just to add insult to injury, the egregious defense campaigns employed by the CMPA hired-gun lawyers financed out of their multi-billion dollar war chest are legendary. CMPA lawyers are notorious for their “scorched-earth” tactics of:

deny the doctor did anything wrong

delay, delay, delay

attack the plaintiff

appeal, appeal, appeal

You should also be aware the CMPA does not provide medical malpractice insurance. The CMPA provides high-priced lawyers to doctors. Very few doctors in Canada have actual liability insurance from bona fide insurance providers (they’d have to pay for that themselves). Instead, they rely on the publicly funded CMPA to get them out of any scrape they find themselves in.

And the CMPA’s financing of a doctor’s defense is not limited to medical malpractice issues; they also fund the defense of a doctor accused of civil or criminal offenses. Maimed a patient? Operated on the wrong body part? Slandered someone? Sexually assaulted a patient? Got nailed on a DUI? Committed OHIP fraud? Don’t worry – the CMPA lawyers are all over it. And don’t suppose that the doctor will lose his license to practice if convicted. The Colleges of Physicians and Surgeons, those so-called regulators of MDs and protectors of public safety, are notoriously forgiving of errant, incompetent, and even criminal doctors.

And here’s another disturbing fact: it doesn’t matter how many civil or criminal predicaments a doctor finds himself in – the taxpayer-funded CMPA lawyers will be there for him time after time.

Is it possible that you have been an unwitting and involuntary participant in healthcare fraud? Find out in part 5 of our series…

Part 5. You May Have Been Unwittingly Been Involved In A Fraud Scheme

Here’s an all-too-common scenario in Canada, based on one story of an actual patient.

This was a 55-year old man who was experiencing problems with his knee. The family doctor referred him to a specialist in a hospital, but when the patient arrived at the hospital some weeks later he discovered that he was scheduled for a series of tests that had nothing to do with his knee. This included a colonoscopy, among other procedures. Alarmed, he told the doctor’s receptionist that he was surprised that this has happened, as he had been expecting his knee to be looked at, and he refused all the tests. At this point the receptionist started whispering that happened all the time at that facility, and that many administrative staff and nurses were upset about all the unnecessary treatments – especially since it was taxpayers that were billed for it. Billing for unnecessary services is fraud.

Apparently, it’s possible for you to be treated by a doctor who isn’t even in the country. ISB Canada has found cases of physicians billing for services supposedly provided at their local treatment facilities while the doctors were actually overseas!

Have you ever been treated by someone other than a physician such as a nurse or a nurse practitioner? Well, there have been cases where patients were treated by such personnel, yet the treatment was billed as having been performed by a doctor because the rate is higher for doctors. There have even been cases where the treating personnel weren’t even qualified to see patients in any capacity. One psychological care facility hired “therapists” who had had no training in the area, and at least one of these bogus “therapists” was hired because he was a friend of the facility’s owner.

Then there was the case of a psychological facility that had a group of unsupervised patients watching a movie that the facility then billed as “group therapy”.

Believe it or not, you don’t even have to be alive to be unwittingly involved in a fraudulent scheme. TVO reports that the Auditor General’s office found $951,900 had been billed and paid out for prescriptions for people who had already passed away. And that was in one year alone (2015-2016).

You may also have received services that you don’t even know about.

In a recent case in Ontario, a doctor falsely submitted claims for a patient’s non-existent conditions. As a result of these imaginary conditions being entered into her medical records, she was unable to get private travel insurance. When she discovered the falsification and asked OHIP to remove the false information from her file, they wouldn’t do it because payments for the procedures had already been made. The patient sued the doctor and one of the doctor’s former employees for fraud.

In one Ontario case, a doctor had labeled many of his patients as having a mental problem and billed the Ontario Health Insurance Plan (OHIP) for these supposed illnesses. The patients knew nothing of this.

Can you imagine going in for a foot problem and getting labeled schizophrenic? Your future is altered and not for the good, and the doctor gets paid by OHIP for it – even though it’s false. Worse still, OHIP might not correct your records!

There are many, many other scenarios you can watch out for. One common example is “unbundling.” In this scheme, a practitioner or a facility takes a bundle of services that are commonly delivered together, and are bundled by the insurance provider at a discounted rate, and bill for the services separately for a higher total rate.

So, just how many ways are there that dishonest practitioners can use to steal money from us? Find out in part 6 of our 10-part series.

Part 6. They Have More Ways To Steal Than You Can Dream Of!

Paul Jesilow, Department of Criminology at the University of California and Bryan Burton, Department of Political Science and Criminal Justice at Southern Utah University specify that:

“Healthcare fraud involves wide-ranging illegal behaviors. It includes such activities as individual physicians who bill insurance companies or the government for services that were never provided, as well as corporate behavior, such as pharmaceutical companies that falsify clinical tests in order to get unsafe drugs approved for use. Thousands die each year in the United States due to these behaviors, including deaths from incorrectly prescribed medications or from tainted drugs that were approved by the U.S. Food and Drug Administration based upon fraudulent testing and reporting. Thousands of additional patients likely are injured and killed by unnecessary surgeries performed by physicians who want to maximize their reimbursements. The illegal activities also add billions of dollars each year to the total healthcare cost in the U.S. Despite these costs, there is relatively little outrage as a result of the behaviors, largely because they remain hidden from public view.”

One of the greatest scams in Canadian history involved Ontario and Alberta paying hundreds of millions of dollars to American hospital chains to treat people for addiction. The hospitals had hired “bounty hunters” who picked up people off the street in Canada to send to these facilities. The “patients” were promised a vacation at taxpayer expense and when they got to the U.S., their “treatment” often consisted of barbeques with hamburgers and hot dogs. They returned in whatever condition they left, and the government paid $150,000 for each of them. And although it was widely exposed in the media, the government did everything in its power to squash the issue. The money was never recovered from the American hospital chain.

In California, there was a case of a hospital that billed Medicare for more than nine years and with more than 150 beds that earned millions of dollars in fees. There was only one problem: the hospital had never been built.

Then there were all the Ontario cases for supposed patients being treated for addiction by Methadone. The patients billed for were street people. Their identities had been procured and were being used to bill taxpayers, but it was nothing but a scam as hundreds, if not thousands, of them did not even reside in the facilities that were doing the scamming. Not to mention that none were ever recorded as cured.

In April 2016 it was exposed in the National Post, headline reading “Methadone doctor accused of coercing patients into using pharmacy linked to his clinic: Patients said the Brantford doctor threatened to cut off their take-home doses and physically walked them into the store, according to a disciplinary ruling.”

Then there are:

Billing for “phantom patients”

Billing for fabricated conditions

Billing for medical goods or services that were not provided

Billing for more hours than there are in a day

Paying or receiving a “kickback” in exchange for a referral for medical goods or services

Concealing ownership in a related company

Using false credentials

Double-billing for healthcare goods or services not provided

Billing for a non-covered service as though it were a covered service

Misrepresenting the provider of the service

Dispensing a lower-cost drug and billing for the higher-cost one

False or unnecessary issuance of prescription drugs

Billing for drugs never dispensed

Unnecessary surgery and other procedures

And several hundred more

How is it even possible that this magnitude of fraud can occur? Is it difficult or even impossible to detect? Emphatically, no. Keep reading – we cover that in part 7 of our series.